Project Summary/Abstract Harmful behaviors (e.g., harm to self or others) resulting from rapidly increasing distress are unfortunately common experiences on adolescent inpatient units. These harmful behaviors often lead to ?interventions of last resort? like seclusion and restraint, rather than more proactive methods (e.g., de-escalation) that might have been effective before the distress escalated. One way to improve the efficiency and efficacy of inpatient psychiatric care and reduce the use of seclusion and restraint may be to identify distress as early as possible before the distress escalates to the point seclusion or restraint is needed. The current standard of care in adolescent inpatient psychiatry is continual or near-continual physical observation. This is a useful to identify harmful behaviors and intervene accordingly because clinical staff can see these behaviors as they occur. Routine observation on its own is less useful, however, to detect harmful behaviors before they start because distress is not often physically observable in its early stages and adolescents may not be aware of their distress escalating. This means that routine observation misses a critical window of time where proactive interventions may still be highly effective. One way to identify distress early in the process of escalation is to monitor physiological correlates of distress that may be apparent in the early stages of distress before other signs are visible, which would signal a window of time where proactive interventions are still viable options. Psychological distress leads to a physiological state of autonomic nervous system (i.e., sympathetic) arousal associated with preparation to cope such as elevation in heart rate and secretion of sweat. Although not always directly observable, this arousal is present as soon as psychological distress begins to escalate, meaning that these physiological signals of distress may be detectable before other physically-observable signs are apparent. The goal of this study will be to use these physiological signals to detect, as early as possible, psychological distress and the harmful behaviors that distress leads to. Participants will be 100 adolescent inpatients (ages 12 ? 19) at Franciscan Children's Hospital in Brighton, MA who will wear a commercially-available physiological monitoring device (Empatica E4) for the duration of their inpatient stay. Distress will be assessed through self-report (Participants will be asked to press a button on the Empatica E4 whenever they are experiencing distress) and through record review. Harmful behaviors will be assessed through record review. The major specific aim of this study will be to test to what extent physiological correlates of distress predict (a) harmful behaviors above and beyond observation or self-report and (b) clinical interventions to harmful behaviors. Secondary aims of this study will assess acceptability and usability of the wearable devices among patients and clinical staff, which will be used to further inform development of clinical decision-making tools in future studies. This study is the initial step in a long- term line of research that will create a user-friendly, evidence-based tool that can be used on inpatient units as part of a collaborative plan to help clinical staff make decisions about managing harmful behaviors and to help patients better identify their distress.